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The Heart of the Matter

Conquest -
Fall 2008

By Julie Penne

It takes a lot of heart to battle and live with cancer. But when patients have to confront both cancer and heart disease — still the top two leading causes of death in Americans today — they need a full-service cardiology team that knows cancer and an oncology group that respects the impact that many lifesaving cancer therapies can have on the heart.

At M. D. Anderson there are both.

Edward T.H. Yeh, M.D., chair of the Department of Cardiology, is leading a growing team of clinicians and basic scientists that is defining the role of cardiology in cancer care.

“Cardiology has a unique place at M. D. Anderson, and as we successfully treat more and more people for their cancer, we know that some patients’ hearts are weakened or damaged,” says Edward T.H. Yeh, M.D., founding chair of the Department of Cardiology. “This presents a conundrum for our team, but it’s also an obligation to protect our patients’ hearts, expand our research and build a new discipline in cardiology. In many ways, we liken cardiology in the cancer setting now to what cancer prevention was two decades ago, and, certainly, M. D. Anderson was a pioneer in that field of study.”

As the only comprehensive cardiology department at any cancer center, M. D. Anderson’s clinic has more than doubled the number of patients seen in the last eight years. In 2000, three cardiologists and two physician assistants saw about 1,700 patients in the clinic and made about 3,700 visits to hospitalized patients. Today, with 10 cardiologists, two physician assistants and four advanced practice nurses, more than 4,900 patients are seen in the clinic and more than 7,300 inpatient consultations are done. In 2000, there were more than 38,500 inpatient and outpatient procedures performed — chiefly EKGs and echocardiograms — while this year, approximately 75,000 procedures will be done.

Don’t lose heart — there’s good news

The increase in patients is due to a variety of factors, notes Yeh and other faculty. Unanimously, they report the increased use of a class of chemotherapies, known as anthracyclines, and the new targeted therapies as the primary reason for the increase in patients with cardiac damage and, when left untreated, heart failure.

Isaam Raad, M.D. (left), chair of the Department of Infectious Diseases, Infection Control and Employee Health, and Jean-Bernard Durand, M.D., associate professor in the Department of Cardiology, compare experiences with the antibiotic-coated pacemaker that has helped decrease the infection rate among patients who get the device. Raad developed the coating more than a decade ago, and Durand now implants the pacemakers in patients with severe heart failure. (See related article below.)

While highly effective in the treatment of many cancers, some of these drugs were found to cause hypertension and induce heart failure. Though not all patients receiving this class of drugs are affected, the rate can be significant. For example, bevacizumab (Avastin) causes hypertension in 23% to 34% of patients and is life threatening in 14%. Other common chemotherapies that can induce heart failure include bortezomib (Velcade), trastuzumab (Herceptin) and sunitinib (Sutent).

“We have found that some patients will survive their cancers but die from heart disease exacerbated or caused by the therapies,” says Daniel Lenihan, M.D., professor in the Department of Cardiology. “It’s vital that we get in at the beginning of patients’ treatments to make sure their hearts are strong. But it’s also important that we monitor these patients throughout their treatment because the good news, in all this not-so-good news about these therapies, is that we can treat and often reverse these heart conditions.”

According to Jean-Bernard Durand, M.D., associate professor in the Department of Cardiology and one of the original three faculty, a beta blocker or ACE (angiotensin converting enzyme) inhibitor are often the most effective therapies for treating heart failure. For more severe cases, he says, a pacemaker or other options may be considered. (See related article below.) Durand founded the cardiomyopathy services at M. D. Anderson, the first heart failure service at a cancer hospital.

Measuring risk early

As one way to get ahead of heart problems as early as possible, or better yet to prevent them altogether, M. D. Anderson cardiologists are studying a simple blood test called the BNP, or brain natriuretic peptide, that could predict heart failure in some patients. Results of a patient’s BNP are an early indication of cardiac dysfunction caused by cancer treatments. Plus, they help guide both cardiologist and oncologist toward the optimal treatment program.

Another valuable tool in assessing how the heart will hold up in treatment is echocardiography. This evaluation technique measures certain heart functions, including the calculation of “ejection fraction,” a numeric measurement of how effectively the heart is pumping on each beat.

“It’s imperative that we’re precise in reporting findings to our oncology colleagues regarding ejection fraction because it’s evidence of how the heart is reacting to cancer treatment,” says Juan Carlos Plana, M.D., assistant professor in the Department of Cardiology and director of Cardiac Imaging.

“In many instances, it’s this test that determines what type of treatment will be given to a patient or if a lifesaving chemotherapy can be continued.”

In addition to following patients who have chemotherapy-induced heart failure or high blood pressure, the cardiology team monitors and fortifies a growing number of patients for cancer treatment or surgery. These are people with pre-existing heart conditions, high blood pressure or high cholesterol or those who have had recent surgery such as bypass or valve repair. In addition, the cardiology team often consults with the surgical and anesthesia teams regarding patients who may have stents and are taking the necessary blood-thinning medications.

Community cardiologists to see more survivors

What distinguishes M. D. Anderson cardiologists from community cardiologists is that they treat patients with two serious diseases at the same time, Lenihan says. But as the number of survivors increases, community cardiologists could see many more cancer survivors who have lingering heart conditions.

That’s why the cardiology team is working to establish collaborations with community cardiologists and other cancer centers, to present more cancer-related studies at national cardiology meetings, to publish more cardiology studies in peer-reviewed oncology journals and to push for more attention to the increasing cardiology needs of cancer patients.

Later this year, one of cardiology’s major organizations, the Heart Failure Society of America, is expected to publish guidelines for more standardized yet aggressive treatment of cancer patients and survivors. It’s a major step towards bringing more awareness to the many needs of cancer patients and survivors who also suffer with heart ailments and the need for more research.

Cardiology cross-pollinates with nearly every service at M. D. Anderson and has worked on translational research projects with other clinical departments. The department also has a strong basic research program on both cancer and heart disease. For example, Yeh’s group discovered a crucial link between hypoxia, or low oxygen, and cancer, and collaborates with M. D. Anderson oncologists to use adult stem cells to treat heart disease.

“This is an exciting time to be working in cardiology and cancer, and there are many who are anxiously watching our patient care and research programs progress,” Yeh says. “What we do today and in the years to come has the potential to touch millions of lives, not just at M. D. Anderson but all over the world, and we welcome newcomers to the field we are creating.”

When Jean-Bernard Durand, M.D., began using a new type of pacemaker earlier this year to reduce the risk of infection, he switched to a device that was enveloped in a clear antibiotic coating. Little did he know until several months later that the drug combination used in the protective sleeve was invented by an M. D. Anderson colleague — and it worked.

Durand was not satisfied with the 2 percent infection rate among his patients getting pacemakers. Though 2 percent is considered low in a general hospital setting, he was concerned that any infection could be serious for patients and delay their continuing cancer therapy.

In addition to examining all other possible risks for infection, Durand turned his attention to using a pacemaker coated in an anti-bacterial envelope. The same device that’s implanted in the chest to regulate a heart beat, this pacemaker has a coating that slowly disintegrates into the body and releases antibiotics to fight infection.

After a few procedures with the new pacemaker and noting the decline in infection rates, Durand mentioned the new device to Isaam Raad, M.D., chair of the Department of Infectious Diseases, Infection Control and Employee Health at M. D. Anderson, who also was pleasantly surprised that his invention had been adapted for use with pacemakers and was contributing to positive infection control. According to Durand’s initial observations, the new pacemaker is yielding zero infections thus far.

Though he sold the rights to his concept and formula about 10 years ago, Raad originally developed and adapted the antibiotic drug combination for central line and urologic catheters, major points of entry for infection for cancer patients. Thousands of these coated catheters are in use every day throughoutM. D. Anderson and the United States.

“I knew Dr. Raad would be thrilled that we were reducing the rates of infection among our pacemaker patients, but he was even more enthusiastic when he heard that it was due in great part to his antibiotic scaffolding,” Durand says. “It’s great to be using a product that’s not only effective but also homegrown.”

The antibiotic-coated pacemaker envelope is manufactured by TyRx Pharma Inc., of Princeton, N.J.

– Julie Penne

Cath Lab a Fundamental at All Major Hospitals, a Vital Novelty at M. D. Anderson

Come early next year, M. D. Anderson patients needing more thorough cardiac evaluations and some procedures will be able to stay on campus and be treated by the team they know and who knows them.

In January, M. D. Anderson will open a diagnostic catheterization lab, the first cath lab to operate at a cancer center in the United States.

Similar to the common technology at any major hospital in the United States, M. D. Anderson’s cardiac catheterization lab will be used in the first year chiefly to perform diagnostic procedures and conduct research. First proposed about five years ago as a fundamental step in advancing cardiology and patient care, the department projects completing more than 300 diagnostic procedures in the first six months of operation.

Leading the project is Cezar Iliescu, M.D., assistant professor in the Department of Cardiology, who came to M. D. Anderson in June from The University of Texas Health Science Center at Houston. Iliescu, who rotated through M. D. Anderson as part of his cardiology fellowship, was struck by the innovative care and the opportunity to work with major influencers in cancer and cardiac care.

“In addition to enhancing the care of our patients, the cath lab will open up new opportunities for cardiac research that’s cancer specific,” Iliescu says. “We’ll be able to see coronary heart disease from the inside and better understand how cancer influences heart disease and vice versa.”

In the past eight years, as needs for cardiac care and diagnostics have increased, M. D. Anderson cardiologists have been forced to transfer patients to neighboring hospitals and hand off their care temporarily to colleagues who know hearts but who don’t have extensive experience with the hearts of cancer patients. It’s a traumatic and difficult decision for both M. D. Anderson cardiologists and patients.

“It’s very difficult to tell patients and their families that we don’t have the technology to do an important test when they have come to the best cancer center in the world,” says Daniel Lenihan, M.D., professor in the Department of Cardiology. “For the physician, it’s tough to turn a patient over to another team, and it’s hard for the patient to leave a comfortable environment. Having our own cath lab truly will revolutionize how we care for our patients.”

– Julie Penne

Conquest - Fall 2008

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